HL7 Partners Value Based Care Breakout Partners Value Based Care Breakout Shahid N. Shah Entrepreneur-in-Residence AHIP Innovation Lab

HL7 Partners Value Based Care Breakout

Shahid N. Shah

Entrepreneur-in-ResidenceAHIP Innovation Lab

www.netspective.com 2

@ShahidNShah HealthcareGuys.com

Agenda

• Introductions

– Facilitator

– Participants

• Overview of breakout session purpose & goals

• Overview of AHIP IL approach to VBC innovation

• Value Based Care facilitated discussion

• Open discussions



Meet Shahid, VBC breakout facilitator

• Technology Strategist and Entrepreneur in Residence (EiR) for AHIP’s Innovation Labhttps://www.ahip.org/innovationlab/

• Chairman of the Board at Netspective Communications and Citus Health; Publisher at Netspective Media and serial entrepreneur.

• Angel investor, board member, in several digital health and Internet startups.

• 25 years of software engineering and multi-site healthcare system deployment experience in Fortune 50 and public sector (Fed 100 winner).

• 15 years of healthcare IT and medical devices experience (blog at http://healthcareguy.com)

• 15 years of technology management experience (government, non-profit, commercial)

Engineer, strategist, entrepreneur,

investor, author, and journalist

http://healthcareguy.com/


Rahul Dubey

AHIP SVP

The AHIP Innovation Lab (“IL”) is a proven value-add/free service

for AHIP Payers/IDN Members to help participants get real work

done.

Explore multi-stakeholder multi-

institution (MSMI) ecosystem

challenges and “stated needs” one

member at a time

(or with their partners)

Consumer | Payer | Provider | Pharma | etc.

Individual Members Bring Their

Unique “Stated Needs”

First, IL is a

“Think” TankThen, IL is a “Do” Tank using

“Solution Working Groups” (SWGs)

Facilitate

Implementation

Document

PTBSs &

JTBDs

Discover

Inflection

Points

Document

Innovation

Strategy

Assist with

Business

Cases

IL Facilitates

Innovation

IL Connects

Innovators

Ecosystem Partners

AHIP Member



How the AHIP IL facilitates value based innovation

Understand management objectives based on desired

outcomes

Consider using Objectives and Key Results (OKRs) framework for defining

outcomes

Understand problems to be solved (PTBSs)

For each PTBS, understand Jobs to be Done (JTBDs)

and journey mapping (JM)

Figure out how to model the PTBSs and JTBDs in

simple spreadsheets or real simulations

Eliminate as many JTBDs as possible through policy or

process redesign

For JTBDs remaining which cannot be removed

(regulatory, statutory, business model, etc.) list

remaining PTBSs

Find or create solutions, based on remaining PTBSs,

JTBDs, and JMs

Test your hypotheses against the models and simulations and keep

what’s evidence driven

These are your “stated needs” (which you’ll use to

influence demand)


There is no interoperability

crisis in the healthcare

industry.

We do have a vendor management and

accountable outcomes measurements

management crisis.



What we’ve been asked to do by HL7

Identify desired

interoperability

business outcomes

• How many of you

think you already

know the business

outcomes?

Define activities to

accomplish the

outcomes

• How many of you

understand the

outcomes enough to

define activities?

• How comfortable do

you feel with process

measures?

• How comfortable do

you feel with

outcomes measures?

Identifying barriers and

challenges

• This is probably the

easiest to do but we

might get stuck here

too long

• Is an Argonaut-style

implementation guide

necessary specifically

for value based care

or that

Remove barriers and

address challenges

• If we can pull this off,

we’d never need to

meet again! :-)



Value based care breakout overview

Background

Health care consumers’ decision-making power is growing as individuals become responsible for more and more of their costs and they begin to increase participation in the care they receive. In order to meet these new demands, “value based” care is considered the best hope for the industry to come together and become more consumer-centric.

But this cannot be accomplished by focusing on one entity (the consumer) alone. It requires a new way of thinking about innovation across the ecosystem.

Proposed takeaways and goals

We must develop multi-stakeholder, multi-institution (MSMI) engagement strategies to improve operational efficiencies and support a value-based design leveraging modern APIs and FHIR to:

• Create an accountable data sharing approach to understand the consumer’s needs, how they are utilizing care, and their preferences for engagement

• Use data to engage stakeholders across the health care industry to improve personalization and deliver the right care management steps at the right time



Are these the right areas for us to focus?

Key questions

• Can we re-engineer care delivery across multiple stakeholders and multiple institutions (“MSMI”) to help control or lower costs and increase quality?– What should we target?

– How will APIs (FHIR, REST, GraphQL) help?

• What financial rewards and incentives are available across MSMI?– Can APIs help improve the incentives

and distribute those rewards?

Potential deliverables

• Identify a population and focus on

the most expensive patients or the

most impactable patients?

– Proposal: pre-diabetics? Impactable?

• Value is derived from lower cost but

costs cannot be lowered and quality

cannot be improved if patients are

not impactable.

– Can FHIR help with risk identification,

cohort preparation, and registries for

most impactable?



Information asymmetry is what FHIR reduces

Value based care will not work with the information asymmetry that exists today – when business interoperability and workforce interoperability across MSMI is properly managed, FHIR is the technology that will help solve information asymmetry across the ecosystem.

Next to the patient, their families, and the MSMI workforces, data is the most important tangible asset that we all share in ecosystem.

Each MSMI knows about data from a transactional perspective but the Partners in Interoperability Program will help identify data(through new or existing FHIR resources) required to manage shared risk contracts and manage incentive programs.


No, value based care will not disrupt

the healthcare “industry” any time

soon.

But small portions can be impacted.

Positively.



Why is disruption in healthcare so hard?

This is $1 Trillion and the

Healthcare Market is three

times this size

This is $1 Billion

“What's not going to change in the next 10 years?”

Jeff Bezos

What's not going to change in healthcare?

Do no harm, safety first, and reliability

effect on standard of care

Statutory cruft & regulatory burdens increase over time

Government as dominant purchaser

Outcomes based payments

intermediation & pricing pressure

Eminence & consensus driven decisions as

collaboration increases

Increased use of alternate sites of care



Inflective vs. Reflexive Innovation

“we need uberization of

healthcare”

“we need to disrupt healthcare”

“how would elimination of co-pays

increase utilization?”

“how can improving provider affinity

increase member satisfaction?”

“we need to buy more digital

health tools”“how can we pay non-clinicians to

handle more patient-facing tasks?”


http://www.stripes.com/va-nurse-practitioners-nationwide-no-longer-need-physician-supervision-1.445862


The BS of “patient centricity” and the

reality of “my institution first”

thinking is a major challenge.

The reasons why are not any one ecosystem

participant’s fault but will require leadership to

solve. ☺


Intermediation continues to growIf FHIR is so easy, why is interoperability so hard?

No single ecosystem participant is incentivized to change long term behaviors in patients so we’re looking to do as little as possible with the most gain for our own institution.


http://jamanetwork.com/journals/jama/fullarticle/2594716

No one funding entity or insurer has beneficiary long enough to be

accountable for long-term care even in a value based environment

AHIP IL Value Based Care Solution Working

Group (“SWG”) Case Study

An innovator’s primary job is to define desired outcomes tied to inflection points



Making it practical

Defining the

objectives

• Overview of

Objectives and Key

Results (OKRs)

framework

• Overview of

Problems to be

Solved (PTBSs)

framework

• Overview of Jobs to

be Done (JTBD)

framework

Strategic Innovation

Planning

• What innovations

are pre-requisites to

using FHIR in VB use

cases?

• Reimbursement

innovation?

• Relationship

innovation

(trust/alignment)?

• Cost / price

transparency?

Implementation

Tactics

• What initial use

cases do we target?

• Recommendation:

Diabetes in Primary

Care

• Patient journey map

and how each touch

point across MSMI

can accommodate

FHIR

Facilitating the

Business Case

• How do we create

the business cases

that implementers

can take to their

bosses to get

funding and

resources?

• How do we identify

bargaining chips for

each decision-

maker?



Value Based Care is hard…we must be realistic

Strategy FinancialWorkforce /

CultureLegal

Process Procedures Measurements Technology

Interoperability Data Middleware



Value is different for each population

• Obesity Management

• Wellness Management

• Assessment – HRA

• Stratification

• Dietary

• Physical Activity

• Physician Coordination

• Social Network

• Behavior Modification

• Education

• Health Promotions

• Healthy Lifestyle Choices

• Health Risk Assessment

• Diabetes

• COPD

• CHF

• Stratification & Enrollment

• Disease Management

• Care Coordination

• MD Pay-for-Performance

• Patient Coaching

• Physicians Office

• Hospital

• Other sites

• Pharmacology

• Catastrophic Case

Management

• Utilization Management

• Care Coordination

• Co-morbidities

Prevention Management

26 % of Population

4 % of Medical Costs

35 % of Population


35 % of Population


4% of Population


Source: Amir Jafri, PrescribeWell



What AHIP IL has seen as VBC challenges

• Gaps in care

• Utilization management / over utilization

• Reimbursement innovation

• Relationship innovation (trust/alignment)

• Workflow / training of healthcare professionals / culture

• New administration and policies around healthcare; speculations vs. regulation

FHIR / Interop / APIs are enablers, not

goals

Let’s talk about what’s important to

you. This is a listening session.


Each population has different value based care inflection points.

Treating members in a personalized approach increases engagement but makes interoperability much harder.



Value Based Care Themes to Cover

Strategy

•How are multiple

stakeholders across

multiple institutions

(“MSMI”) aligning

their strategies

around VBC?

Financial

•What financial

incentives alignment

exists between

MSMIs?

Workforce / Culture

•Are stakeholder

workforces in each

institution aware of

their new roles,

responsibilities, and

RACI charts? Do they

know the new

patient journeys? Are

MSMI trained around

specific OKRs

associated with their

RACI?

Legal

•How can we move

beyond simple

agreements into

more specification-

oriented agreements

that would

memorialize data-

specific expectations

•If something is not

legally required, is it

still important?

Processes &

Procedures

•Are MSMI processes

well understood? Are

the data exchange

requirements

defined and

documented (with or

without FHIR)?

•Are MSMI standard

operating

procedures for each

process well

documented,

trackable,

measurable, and

shared? Are FHIR

resources identified

properly for each

procedure?



Value Based Care Themes to Cover

Measurements

• Have we properly

delineated

process measures

vs. outcomes

measures?

• Are quality

measures defined

well enough to

put them into our

contracts?

• How can we

remove

measurements

over time instead

of increase them?

Technology

• Are each of the

technologies

necessary for

exchanging FHIR

data identified

and procurable

when necessary?

Interoperability

• Has each MSMI

participant’s

business

interoperability

documentation

been approved

and accepted?

We’ll assume

technical

interoperability

will be easy but

what about

business and

workforce

interoperability?

Data

• Assuming FHIR

resources exist,

where will data be

stored and

exchanged (what’s

canonical, what’s

transactional)?

Middleware

• Does middleware

for exchanging

FHIR resource

exist at each point

where an

exchange is

necessary? How

will endpoint

discovery

happen?



Focus on insurers' VBC tasks or help providers?

Providers’ work

Clinical

services

Patient

registries

Recruit

patients

Fill gaps in

care

Coding and

sending claims

for services

Schedule and

coordinate

care clinically

Engage

patients during

clinical services

Payers’ Work

Pay claimsIdentify gaps in

care

Coordinate care

administratively

Engage consumers

pre- and post-

clinical services

Risk scoring and

registry

identification

Identify care

variability across

MSMI

Understand

utilization and

engage network



Aligning Multiple Roles and Responsibilities

Provider-Payer Collaboration – Shared Objectives, Blurring Roles & Vendors that Don't Get it; Janice Young Chilmark Source: Value-Based Care – What Revenue Cycle Impacts should you worry about? Marhefka, et. al.



Where can FHIR / technology intersect?

• Data tools – to pull (Extract, Transform, Load – ETL), house (repository), integrate–aggregate–normalize (manage), mine (analytics), present (reporting/dash-boarding) and push (Health Information Exchange –HIE) data.

• Process Optimization software – to enhance workflows.

• Patient Portals – to enhance communication with patients, better manage prevention, promote wellness and collect cash.

• Social Media tools – to manage patient, provider and business communication challenges now common for integrated care delivery networks.

• Marketing-to-the-Consumer tools – to market services based on price and quality.

• Population Health Management systems – to support care management of defined populations.

• Productivity Management systems – to manage the resource aspect of clinical processes.

• Cost Accounting systems (fortified) – to track costs across the continuum of care.

• Contract Management systems (also fortified) – to provide bilingual type management of traditional FFS based contracts as well as FFV based contracts.

• Enterprise Master Person Index (Patients) – to identify a population and tag patients who are “eligible” under alternative payment models.

• Enterprise Master Provider Index – to support centralized scheduling, referral management and overall patient care coordination.

• Scheduling systems that incorporate Referral Management – to manage patient care coordination.

• Case Management systems – to manage transitions of care.

• Health Information Exchanges – to capture and share patient data from multiple, disparate sites of care delivery.

Source: Value-Based Care – What Revenue Cycle Impacts should you worry about? Marhefka, et. al.



“My institution first” approach to patient care

Insurer | Payer

Product 1

Product 2

Each member population requires different engagement techniques at various times.

But ecosystem participants don’t work together.

Provider 2

Provider 1



Value Based Provider Affinity Approach (SWG)

Insurer | Payer

Product 1

Product 2

Product 3

Each member

population get

personal care

through their

provider or other

advocate, enabled by

health insurer tools

and support.

Provider 2

Provider 1

Influencers

Caregiver



How value based care via provider affinity works

Analyze high cost, high

impact targets (not

necessarily by looking at

demographics)

Design incentive plans

for providers to

participate as influencers

Design incentive plans

for members to work

through influencers and

advocates

Create engagement

tools for health

institutions, caregivers,

and clinicians

Activate health

institutions, caregivers,

and clinicians

Let influencers engage

patients or caregivers by

extending tools to them

Let patients engage

caregivers or vice-versa

through their influencers

and advocates

Track outcomes and

results of programs

through active telemetry

across the network

1

6

The AHIP Innovation Lab can work with you and your partners to develop specific programs and find solutions.



Interoperability opportunities with affinity

General

Wellness

Specific

Prevention

Self Service

Physiologics

Self Service

Monitoring

Self Service

Diagnostics

Care Team

Monitoring

Care Team

Diagnostics

Healthcare

Professional

Monitoring

Healthcare

Professional

Diagnostics

Hospital

Monitoring

Hospital

Diagnostics

Visit

http://www.netspective.com

http://www.healthcareguy.com

E-mail [email protected]

Follow @ShahidNShah

Call 202-713-5409

Thank You!This deck is available at http://www.speakerdeck.com/shah

Need help with your innovation?

Tweet, call or write to me.

Documents

HL7 Partners Value Based Care Breakout Partners Value Based Care Breakout Shahid N. Shah Entrepreneur-in-Residence AHIP Innovation Lab